Frontline employee voice through labor-management partnership in the healthcare setting

by Ariel C. Avgar, Julie Sadler, Paul Clark and Wonjoon Chung

To what extent can labor-management partnership in the healthcare setting enhance frontline employee voice when it come to the care they provide patients? Evidence supporting the relationship between collaborative labor-management relations and patient care voice would contribute to both scholars and practitioners grappling with the ways in which healthcare organizations can improve a host of important and central outcomes.

In a recent article published in Industrial Relations we attempt to better understand the link between partnership and frontline patient care related voice. Specifically, we argue that partnership is most likely to improve frontline patient care voice in units where the process of implementing this labor-management innovation has been supported by egalitarian and inclusive processes.

We find that where frontline employees report partnership processes that allowed for union and management involvement, mutual respect, information sharing and consensus building, they were also more likely to report greater levels of patient care voice. We also find that the relationship between high quality partnership processes and frontline employee voice is mediated by their trust in management. These finding are important given the current state of healthcare in the United States and in many other countries.

In the United States, the healthcare industry faces a large number of considerable pressures and challenges. Hospitals and other healthcare organizations have been struggling to balance the need to advance multiple and often conflicting performance outcomes simultaneously.

Most notably, healthcare organizations and the industry as a whole have been attempting to address persistent and troubling quality of care shortcomings, while, at the same time, curbing the escalating costs of delivering patient care.

In their efforts to address these dramatic and competing pressures, healthcare organizations have been experimenting with a host of organizational and work related innovations including new models for delivering care, alternative employment practices, and new technologies.

One such innovation relates to the relationship and mode of interaction between labor and management in unionized settings. Specifically, a growing number of healthcare organizations and the unions representing their employees have turned to partnership as an alternative to the traditional adversarial labor-management relationship.

A partnership approach moves away from viewing labor and management as adversaries focused on their own interests and on prevailing in the constant battles over resources. Rather, partnership establishes a variety of mechanisms at the strategic and workplace levels for labor and management to work together in an effort to advance a variety of mutually beneficial outcomes.

The potential promise associated with a labor-management pattern rests on the proposition that a collaborative relationship is better suited as a means of improving quality care, reducing costs, and addressing workforce challenges. Employment relations scholars and a growing number of practitioners have advanced the argument that traditional adversarial labor-management relations undermine organizational efforts to tackle mounting pressures. Partnership, on the other hand, offers an opportunity to transform the way management and labor work together to enhance quality, increase efficiencies, and address workforce needs.

At the heart of this transformative view of partnership is the assumption that this labor-management pattern can facilitate and promote frontline employee voice, which has been shown to have a number of organizational and individual level benefits.

Many partnership initiatives in healthcare have been structured around collaboration at the unit level with the expectation that they will provide frontline employees with a supportive climate and opportunity to exercise patient care related voice. This voice, in turn, can help to address organizational deficiencies.

Interestingly, the empirical evidence about the outcomes associated with partnership has been mixed. Furthermore, despite the centrality of voice as a vehicle through which partnership is likely to deliver organizational gains, there is relatively little evidence regarding the factors that are likely to promote it.

The role that voice plays in the context of partnership has often been assumed rather than empirically tested. Even though a relatively large body of literature has promoted partnership conceptually, what we know about how well it does in general and its ability to elicit employee voice in particular is far from conclusive.

Our study attempts to address this ambiguity by examining the relationship between perceptions of partnership and reported patient care voice. Our primary objective was to explore the extent to which the quality of partnership processes is related to employee voice.

We argue that the process by which partnership is adopted and implemented are part and parcel of its ability to improve patient care voice. Put differently, we maintain that the procedural infrastructure on which partnership is set up is a crucial predictor of whether it will yield patient care voice related benefits.

Our study also attempts to examine the mechanisms by which labor-management partnership processes influence patient care voice. High quality partnership processes should improve employee perceptions of both labor and management and this will translate into greater levels of reported employee voice around patient care issues. As such, we expected to find a relationship between the quality of partnership process and employee trust in management and perceptions of union effectiveness.

We examined the link between partnership process quality and patient care voice using survey data collected from members of two healthcare unions working in three facilities. In order to test the relationship between the quality of partnership processes and employee voice, my colleagues and I developed a scale that captures important process dimensions that have, for the most part, been assumed in previous research and not empirically documented or captured.

We find that the perceived quality of labor-management partnership has a direct effect on reported patient care voice. We also find that trust in management, and not union effectiveness, serves as a mechanism linking perceived quality of process and patient care voice.

Frontline employees with perceptions of high quality partnership processes are more likely to report higher levels of trust in management which is, in turn, related to greater levels of reported voice.

The study has a number of practical implications. First, partnership has the potential to contribute to organizational efforts to improve outcomes in healthcare insofar as it can set the stage for improved patient care voice.

Second, despite the potential to advance patient care voice, this benefit is not automatic and is contingent on the procedural infrastructure on which this transformative labor-management patterns is established. Healthcare organizations and unions seeking to leverage partnership as a tool to address healthcare challenges should be sure to engage in an adoption and implementation process that pays careful attention to the level of union and employee involvement, to the nature of interactions between labor and management and to the degree to which the parties share and exchange ideas and information.

Third, partnership processes advance voice, in part, by improving employee perceptions of management. This suggests that other measures that can enhance employee perceptions of management are likely to improve their willingness to use voice to address patient care issues.

Finally, our findings suggest that while improved partnership processes reflect positively on management, it does not appear to affect members’ perceptions of their union’s effectiveness. This suggests that unions engaged in labor-management partnership may want to explore ways to create a clearer and more explicit link between this mode of interaction with management and their own effectiveness as an organization.

Ariel Avgar is an associate Professor at the ILR School at Cornell University. Julie Sadler is an adjunct faculty member at Pennsylvania State University. Paul F. Clark is Professor of Labor and Employment Relations at Penn State University. Wonjoon Chung is a doctoral candidate at the School of Labor and Employment Relations at the University of Illinois at Urbana-Champaign.